Provider Demographics
NPI:1255418414
Name:MALCOLM, MILLICENT M (APRN)
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:M
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:520 SAYBROOK RD
Practice Address - Street 2:SUITE N100
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4700
Practice Address - Country:US
Practice Address - Phone:860-344-1801
Practice Address - Fax:860-358-8657
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002258363LF0000X, 363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4208296Medicaid
CT004208296Medicaid
CT4208296Medicaid
CT500000466Medicare PIN
CT500001929Medicare PIN